In 1966 thirty-four male heroin addicts living in the area served by the South West Metropolitan Regional Hospital Board were admitted into Salter Narcotic Addiction Unit of Cane Hill Hospital, Coulsdon, Surrey. Fourteen of them were admitted as informal patients (of whom three were on probation), twelve at their request under Section 26 of the Mental Health Act, 1959, which empowers a hospital to detain a patient for up to a year if necessary, seven others under Section 4 of the Criminal Justice Act, 1948 as a condition of a Probation Order, and one from prison under Section 60 of the Mental Health Act. (After the period covered by this survey a change of policy was made and later addicts were seldom taken in under Detention Orders.) The average stay of each resident in the Unit was nineteen weeks (range one week to forty-five weeks). Fifteen of the patients had been hospitalized previously for drug dependency, of whom two had had three such admissions. Two had been introduced to heroin while in other hospitals for amphetamine dependency.

If an addict is asked whether he wishes to be treated for his addiction he is likely to refuse. As the World Health Organization (
[
1] ) puts it, there is "an overpowering compulsion to continue taking the drug and to obtain it by any means", and most addicts feel forced to continue with their drug of addiction. Thus, only a minority will agree to accept treatment and those who ask to be admitted to a treatment unit are likely to be an uncharacteristic sample of the addict population.

This being the case, the information collected and here presented must be seen as representative not of the narcotic addict population as a whole but of an atypical self-selected group who had for one reason or another decided to cease taking heroin. The reason for this decision was usually that the addict had realised that heroin had effectively shackled him and that he had become an appendage to something which tethered him physiologically and psychologically (i.e body ands soul). For a long time he would probably have been alternating between despair and desperation-despair after he had made himself "straight" with an injection of heroin and recognized that his life was empty of real pleasure, desperation when he was shortly due for a fix but had not yet got the heroin for one.

Naturally it was the more intelligent addict who recognized what was happening to him and asked for help. He did so either by a direct appeal to the hospital service or to his general practitioner, or indirectly by doing something which would bring him into contact with the law and through the law to psychiatric intervention. Twenty-two of the thirty-four addicts were referred by the general practitioners treating them (including the small number of "junkies' doctors"). Three were self-referred, three were seen in prison and one in a remand centre, two were referred by other hospitals, two by a local health authority, and one by a probation officer.

When we were first contacted, in whatever way, if the addict was living with his family and he had not told them of his addiction it was our policy always to try to persuade him to confide in them. This was of some importance because if he did not do so there was bound to be an atmosphere of suspicion and misunderstanding within the family which was contra-therapeutic. However, if an addict could bring himself to tell them he usually found, to his surprise, that the family was supportive and helpful. Condemnation did not come at this stage. Where it would be in the addict's interests, one of us (H.D.B.) visited him at home so that he could be seen within the family setting and family relationships examined. It was thought also that this important first contact was best made in sur- roundings familiar to the addict rather than in a hospital setting. The patient was interviewed first, a full history taken and an evaluation of his personality made. Following this the rest of the family were seen, with the addict excluded, their personalities examined and independent accounts obtained from them. Finally the addict and his family were interviewed together and their interactions explored in a number of areas.

During this final session the question of treatment was raised. Since treatment within a hospital seemed likely to be more effective than treatment outside it, it was, of course, the first possibility considered. Only if the patient was too old (over 40), on heroin too long (ten years or more), or so apparently brain-damaged by cocaine that he could not be expected to maintain his resolve to come off heroin was he not offered admission to Salter, and in these cases he was given an appointment to attend an attached psychiatric out-patient clinic for a withdrawal course. However the compulsive need for" freedom" at any cost, which is a personality feature of many heroin addicts, frequently prevented even well-motivated patients from accepting hospital treatment. For them too, out-patient withdrawal was offered.

Those others who were capable of assessing their priorities realistically and agreed to in-patient treatment were offered an appointment to attend the Unit for an assessment meeting. In this assessment in Salter itself the new candidate was interviewed by the patients already there in order to determine whether he was likely to be able to profit by admission. If he was accepted he was given a date for admission and, in fact, between the time of the institution of the assessment meetings in March, 1966 and the end of that year, no prospective patients were turned away.

From time to time an addict was seen in prison or remand centre where he had been remanded in custody. Naturally it was often suspected that he had elected to go into hospital as a means of avoiding a prison sentence. This situation posed a very real problem. Was one to take his protestations at face value and allow him to come into hospital? If, as was likely, he was deceiving his interlocutor and possibly himself about his intentions, his admission would imperil the motivations of the patients already in treatment while in the long run he himself would not benefit. Consequently the selection of such potential patients was done very carefully and their subsequent assessment by the group carried out with even more rigorous scepticism than usual.

The average age of onset of addiction to heroin was twenty years. One became addicted at fifteen, three at sixteen, whilst two avoided this affliction until after the age of thirty (see table 1). Most were "registered ", meaning that they obtained their supplies of heroin legally from a doctor who gave them prescriptions for it, but even so a considerable number of them supplemented their supply by the use of the black market.

Patients often came from homes headed by a successful father as, for example, a government executive officer, two bank managers, a buyer, a grocer who had built up a small chain of shops, a company director and a house-master (see table 2).

In contrast to Hewetson & Ollendorff's patients, of whom one-fifth were near-illiterate, the educational level of the Salter Unit patients was generally higher though in none was the ability to graduate found (see tables 3 and 4).

Of the thirty-four patients twenty-nine (85%) had had a considerably diminished opportunity of establishing normal relationships during their formative years. Six told of exceptionally poor communication with their fathers. For example, one father used to address the boy through the child's mother, two fathers had had unhappy childhoods themselves and seemed unable to communicate other than by means of hints, two fathers were assaultive drunkards who intimidated their children and another alcoholic father was uninterested in his son and rarely talked to him. Then two children were separated from their parents for long periods, one between the ages of 5 and 13 because of hospitalization with tuberculosis of the hip followed by poliomyelitis, and the other intermittently up to the age of 15 because his parents were on the stage and rarely saw their child. Five children had been adopted, three of them having spent some time in children's homes. Two other boys were in homes between the ages of 4-15 and 5-15 years because the fathers had left the mothers. Another boy was an illegitimate baby brought up by his natural mother and her husband.

The father of one child was killed in the war before the birth of the infant, who was brought up by his mother who remarried when he was 11. The parents of another deserted him when he was 4, he was brought up by his grandmother till he was 11 and then he went into a home for maladjusted children. The mothers of seven died, when the patients were 14, 14, 13, 12, 12, 11 and 6 years old. Four fathers died when the patients were 15, 10, 2 and 2 years of age. (The ten-year old found the body.)

In addition to the separate instances referred to above, in eighteen of these twenty-nine children relationships were further disturbed by factors such as parental heavy drinking, threats of suicide, physical or psychiatric illness, eccentricity, unemployment, monetary extravagance, etc. Naturally, the manifestations of these traits impinged upon the children, as also did strict discipline which sometimes escalated to frank ill treatment of the patient. Perhaps it is not altogether surprising that a mother who always left her unwanted child to cry, without picking him up, said later that he had never been a cuddly child. The surprise is that these experiences resulted in overt childhood neurotic manifestations in only twenty of our patients, with pubertal disturbances in another five.

Neurotic manifestations often continued in the form of nail-biting, enuresis, stealing from home, nightmares, truancy, attempts at suicide and an inability to express feelings. As might be supposed, rebellion against authority was frequent but such acting-out behaviour was taken note of by the law in only eleven instances, producing seven probation orders and one committal to an approved school. Six boys were expelled from their schools.

TABLE 5

Before addiction eleven out of the thirty-four had been to Court. After the onset of addiction fifteen others became first offenders. At this stage of the addiction the young men's health was deteriorating and their ability to work steadily was declining. It will be seen from table 6 that most of the offences were committed for gain. The offences in contravention of the Dangerous Drugs Act and Drugs (Prevention of Misuse) Act find their expected places in the list. Of the thirty-four patients only eight appear to have kept clear of the courts before treatment in Salter (see table 6).

(iii) During and after residence in the Salter Unit till the end of 1967

7 new probation orders were made

1 was sent to Borstal

4 were imprisoned

As may be seen, many social workers have been involved in the extended care of the addicts. At least twenty-nine probation officers throughout the country were at some time directly involved with twenty of them before, during and after their stay in the Salter Unit. (One of us-K.J.L.-visited the unit on forty-six occasions and attended twenty-eight group meetings in the year. Thus a relationship was structured between the addict and the probation service and after-care rehabilitation could be more effectively carried out.) Ten local probation officers also visited patients known to them so as to maintain an on-going relationship. The value of this kind of support by the probation service during treatment and rehabilitation is pointed out in the report on rehabilitation by the Advisory Committee on Drug Dependence. To quote, "Community social workers, including probation and child-care officers ... should be encouraged... to make or maintain contact with the patient before he leaves hospital" (
[
4] ) and "Many drug takers commit offences especially against the drug laws. The courts, prison service, and probation and after-care service should have a positive role in rehabilitation." (
[
5] ) However, dealing with this new social phenomenon may be easier said than done. The expanded role of the probation officer and the difficulties he experiences in such a setting are already recognized (
[
6] ).

Since addicts, particularly when under-prescribed, frequently commit anti-social acts in order either to obtain drugs or to obtain money with which to buy drugs, it is clear that the probation service will continue to be the social agency most likely to be in contact with the addict. So the social worker to whom any addict should be able to turn and find understanding and tolerance is the probation officer, but, not suprisingly, the patients initially saw him as part of the judicial system they regarded as ranged threateningly against them. Moreover, several patients remarked that they did not know that they could call and see a probation officer without being on probation.

Twenty-four members of the group were single. Of the ten married ones seven were separated. In three marriages the wives had also at some time been taking heroin.

TABLE 6

Prior to any drug-taking

Between taking any drugs and treatment for heroin addiction 1966

During treatment

After discharge to end of 1967

Total

OFFENCES

For gain or in contravention of the Dangerous Drugs Act

Larceny or theft

8

6

3

17

Possession of dangerous drugs

8

3

11

Forgery of prescriptions

3

2

5

Attempt to procure drugs

1

3

4

Breaking and entering

1

2

1

4

Post Office fraud

4

4

Rail fraud

1

3

4

False pretences

1

1

2

Embezzlement

1

1

Robbery

1

1

-

-

-

-

-

10

25

1

17

53

Miscellaneous

Road Traffic offences

2

4

1

1

8

Breach of probation

4

4

Drunk and disorderly

3

3

Assault

1

1

2

Breach of peace

2

2

Malicious damage

1

1

Loitering

1

1

Wandering abroad

1

1

-

-

-

-

-

3

12

1

6

22

-

-

-

-

-

TOTAL OFFENCES

13

37

2

23

75

OFFENDERS

11

20

2

12

26

Court decisions

Probation

7

14

7

28

Fines

2

10

1

4

17

Prison

3

1

1 (1 day)

2

7

Conditional discharge

1

1

2

Hospital under Sec. 60 Mental Health Act

2

2

Approved School

1

1

Borstal

1

1

Absolute discharge

1

1

NOTE. The four breaches of probation after discharge (further offences while on probation) were dealt with as follows: six months' imprisonment, three years' probation, two fines.

The descriptions of the ten wives by the various social workers who had dealings with them varied from "good understanding wife" to "immature, possessive, unreliable" and "neurotic". No one personality traitappeared to stand out. Similarly the descriptions of the patients as husbands varied considerably, from "he is masochistic" through "ambivalent love/hate relationship" to "he has always shown responsibility and loyalty to his wife even during his addiction". The marriages had all been experiencing considerable tension and sexual frustration (see table 7).

Of the eleven leaving school at fifteen most of the patients had had brief spells of employment in relatively unskilled occupations such as baker's roundsman, builder's labourer or warehouse porter. Predictably some of the jobs held on leaving school and before the development of drug dependence lasted for a longer time, sometimes for some years. However, before admission six had been out of work, one for two years.

Of those leaving school at 17 or 18 the occupational level was higher, but when account was taken of the patient's intellectual capacity and education it was often not as high as might have been expected. Nevertheless, occupations included student teacher, insurance clerk and musician.

There was only one example of rebellion against a strict religious upbringing. In other cases it seems that religion was not a parental obsession. During the period of addiction there often appeared a noticeable interest in spiritual matters-and it was at this point that a number became actively interested in Buddhism, especially the Zen school. The usual Christian churches did not apparently attract the addicts, one of whom expressed feelings of unease because of the persecution and crucifixion of Christ (see table 8).

TABLE 8

Church of England

13

Buddhist

7

Roman Catholic

5

Agnostic

4

Congregational

1

Church of Scotland

1

Jewish

1

None

2

-

34

NOTE. Sixteen (47%) had changed their religion from that of the parent who they felt was the closer to them.

During the period of rehabilitation two stayed for a time at a home run by Narcotics Anonymous-an evangelical trust. One seemed to have responded to this.

The members of the group were discharged individually in 1966-1967. Seven were believed to be still taking heroin and were expelled from the Unit by their peers. In all, within the first year the number back on heroin was twenty-five; twelve of these were again admitted into hospitals (two back to the Salter Unit). The remaining nine progressed well and were off heroin on 31 December 1967, whilst still being under medical care.

Following their discharge and up to the end of 1967 fifteen of the thirty-four (44%) were under the supervision of the bation service and one continued to be under the guidance of a child care officer (see tables 9 and 10).

TABLE 9

Place of discharge

No.

Back on Heroin on 31.12.67

Percentage

Home to parents

19

15

79

Home to wives

4

2

50

Bedsitters, flats, lodgings

9

7

78

Hostels

2

1

50

TOTAL

34

25

73

TABLE 10

Medical after-care

There is a point, some way along the path of addiction, before reaching which heroin produces a marked sensation of pleasure and gratification ("smothered in luxuriousness") in the potential addict. During this period a fix of heroin changes his disturbed mental state from abnormal to what appears to him to be a transport of pleasure but which may be no more than a quite new and astonishing experience of the general sense of wellbeing which is accepted as natural by most people. After this point has been reached, however, because of the development of physical tolerance and psychological dependence, heroin merely changes the state of the user from abnormal to comparatively normal. The old sensation of euphoria becomes progressively reduced to zero as the new mental state is accepted and the contrast with the previous one loses its impact.

There is in fact a total downward shift because, when an addict has gone without heroin, to the resurgent original painful abnormality is added a new one comprising physical withdrawal symptoms and presumably a psychological homeostatic mechanism which fruitlessly flails away in a puny attempt to put matters right.

The proportion of adolescents in the total of addicts admitted to Salter in 1966 (23.5%) reflects the proportion of adolescents in the addict population outside in the same year (25%), (table 1). It is perhaps surprising that so many adolescents did seek treatment, since from first principles one might suppose that someone recently addicted to heroin would still be deriving positive pleasure from it and would not easily be persuaded that its disadvantages outweighed its advantages. It would certainly seem that the three times as large (70.5%) incidence of admission of young adults between the ages of 20 and 34 indicates the passing of the point beyond which heroin produces progressively less pleasure. This figure is almost double the 41% in this age group identified by the Home Office in the community during that year, and seems to indicate a certain disenchantment as one goes on with heroin addiction and its related frustrations.

It may be seen that there is a noticeable skew towards the higher social classes (table 2). This may be due to selection pressures which it has not been possible to identify but which may partly be due to the comparison which an addict from a comfortable middle-class home may make between his present standard of living and his previous one. This may conceivably have acted as a spur to treatment. Similarly (table 3), the relatively high educational level of Salter admissions may point to the possibility that the better educated addict is more likely to appreciate the penalties of remaining addicted.

The importance of stable childhood relationships is brought out in the data presented in section 5. That twenty-nine out of thirty-four suffered a rupture or disorder of their parental relationships is significant (P = <0.08). A child subjected to the volcanoes and earthquakes of an unstable emotional environment is almost bound to carry echoing volcanoes and earthquakes inside his head as he matures to adulthood. Greer (
[
7] ) found that parental loss was relatively common in the history of suicidal patients and if heroin addiction is seen as a timorous sort of suicide (
[
8] ) his findings receive confirmation here.

The association of rebellious and anti-social activity with a wide range of neurotic manifestations seems to indicate that serious rebellion may be but one example of neuroticism. The same may be said of heroin use itself, and it appears to us that addiction to heroin is a manifestation of neuroticism. The association of other drug taking with heroin (table 5) seems to support this conclusion, for it may well be that a depressed adolescent with a wounded personality as a result of traumatic childhood experiences looks neurotically for some acceptable sort of calm, so that he can begin to solve life's many problems with which he is so ill equipped to deal. This calm he hopes to find by taking drugs,-and possibly only when he discovers that the minor drugs such as cannabis, amphetamines, barbiturates or alcohol do not help him does he turn to heroin and cocaine, which he counts on to banish his problems altogether. If this is so, the availability of these minor drugs may serve to filter off a number of disturbed adolescents who otherwise might turn to heroin
ab initio.

The association between delinquency and heroin addiction is an interesting one. If much delinquency as well as much heroin addiction can be identified as a manifestation of neuroticism, then it follows that many heroin addicts will carry out criminal activities for reasons not directly connected with the addiction. However (table 6), it would seem that of greater incidence are crimes carried out in order to satisfy his need for heroin. Possibly the Courts should separate out these two types of crime and while punishing the former appropriately, recognise the latter as being one of the symptoms of narcotic addiction and act accordingly, possibly by using probation orders with a condition of treatment. That magistrates seem already to be aware of the distinction can perhaps be inferred by the negative finding that none of our patients had been sent to a detention centre, whereas 11 out of 163 of the offenders using drugs (mainly amphetamines) in the Middlesex Probation Survey (9) had been so sentenced.

Of the Salter Unit patients 32% had had convictions prior to drug taking. This compares with 76% of the sample of fifty addicts in prison investigated by James (
[
10] ). Possibly the less delinquently orientated addict has not been subjected to as much personality damage as his more criminal colleague, so he is better able to appreciate his real needs and opt for treatment. It is of interest that in both series robbery and sex offences are notably infrequent. The association between disrupted parental relationships and subsequent psychiatric disorder and delinquency is of course well known (
[
11] ,
[
12] ,
[
13] ), and is supported by the histories of the patients in this survey.

The stability of relationships during formative years is an augury of the type of relationships to be established later in life. It is of great interest that the marriages of heroin addicts should be so insecure. All in all there seem to be strong reasons for dissuading an addict from embarking upon a marriage.

The occupational record also reflects the instability of the addict and it seems that even if there had been no ultimate addiction to heroin the work record of these individuals would have been disappointing. This lack of achievement would certainly contribute much to a feeling of failure and non-identity in a vulnerable adolescent and be a powerful reason to give up hope, give up the struggle and sink.

The swing away from the religion of the parents is striking. It seems to indicate an awareness of the need for stability together with a hope that this stability can be achieved by some other road than the one trodden by the unstable, rejecting parents.

Although almost a third of the patients were off heroin at the end of 1967, it is almost certain that given their innate instability, some of these ex-addicts when constrained by a painful dilemma will once again turn to a drug which they know will blunt its horns. It would seem desirable that after treatment a heroin addict should be found an occupation which is keyed to his personality, interests and aptitudes, a triangular hole being found for a triangular peg where possible. It may be a mistake, in general (table 9), for an ex-addict to return to the parental environment, where the personality interactions to which he has become sensitized during his formative years are likely still to exist, or to a solitary room from which boredom drives him back to the company of his old addict friends. In general, a permanent cure of heroin addiction may perhaps be compared with a permanent cure of a neurotic depressive reaction, for each may recur at some time as a result of stress. However, if a patient is given the time and the opportunity to mature and to learn how to handle relationships, things and events, which was the therapeutic aim in Salter, this inability to cope with reality may be outgrown.

We would like to express our thanks to D. Simmons, Charge Nurse, Salter Unit, and to F.A. Hepworth, Principal Probation Officer, South East London Probation and After-Care Service, who actively supported the close collaboration of the Probation Service with the Unit.